<div class="content-box">
    <div class="box-header clear">
        <h2><?php echo lang('pg_add_provider') ?></h2>
    </div>
    <div class="box-body clear">
        <?php echo validation_errors('<li class="error">', '</li>'); ?>
        <?php echo form_open(base_url() . 'provider/add'); ?>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_provider_name') ?> :(<span class="required">*</span>)</label>
            <input type="text" value="<?php echo set_value('provider_name'); ?>" name="provider_name" class="text" maxlength="10" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_address') ?> :</label>
            <input type="text" value="<?php echo set_value('address'); ?>" name="address" class="text small"/>
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_address_house_number') ?> :</label>
            <input type="text" value="<?php echo set_value('address_house_number'); ?>" name="address_house_number" class="text small" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_address_postcode') ?> :</label>
            <input type="text" value="<?php echo set_value('address_postcode'); ?>" name="address_postcode" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_address_place') ?> :</label>
            <input type="text" value="<?php echo set_value('address_place'); ?>" name="address_place" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_po_box') ?> :</label>
            <input type="text" value="<?php echo set_value('po_box'); ?>" name="po_box" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_po_box_postcode') ?> :</label>
            <input type="text" value="<?php echo set_value('po_box_postcode'); ?>" name="po_box_postcode" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_po_box_place') ?> :</label>
            <input type="text" value="<?php echo set_value('address_postcode'); ?>" name="address_postcode" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_country') ?> :</label>
            <input type="text" value="<?php echo set_value('country'); ?>" name="country" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_termination_email') ?> :</label>
            <input type="text" value="<?php echo set_value('termination_email'); ?>" name="termination_email" class="text small" id="name" maxlength="200" />
        </div>
        <div class="form-field clear">
            <label class="form-label fl-space2"><?php echo lang('lbl_status') ?> :</label>
            <?php echo form_dropdown('status', $status); ?>
        </div>
        <div class="form_submit">
            <input type="submit" class="submit" value="<?php echo lang('btn_save') ?>" id="save" name="save">
            <input onclick='location.href = "<?php echo base_url(); ?>provider"' type="button" class="submit" value="<?php echo lang('btn_cancel') ?>" name="cancel">
        </div>
        <?php echo form_close(); ?>
    </div>
</div>